the hospice indicators Nightingale Hospice

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1 the hospice indicators TM Nightingale Hospice

2 Hospice is a lot of things, but hospice isn t all about dying, a place to go to die or always depressing. Hospice is about the journey, a place of sharing, an opportunity to help those in need and a safe environment for patients and families not to mention the industry leading, specialized care received by patients. Hospice is a special way of caring for patients, caregivers and family members that is available to people living with a terminal illness. However, that does not mean that patients must be in the last few days of life to qualify for hospice care. table of contents Hospice 4 Nightingale Hospice Improves the Quality of Life For Patients with: 5 Neurological Diseases 6 Patients with Cancer 8 Debility Unspecified 10 Renal Disease 12 Continuous Care 14 Failure to Thrive 16 Cardio Pulmonary Disease 18 Medicare has established industry guidelines to help doctors and hospice staff determine if a patient qualifies for hospice. We are happy to answer any question you may have.... 3

3 Hospice Congestive Heart Failure: Class IV functional status (NYHA) Ejection fracture of < 20% Optimal diuretic and vasodilator therapy Recurrent symptoms of CHF at rest Liver Disease: Documentation of specific liver disease Jaundice Abnormal liver enzymes Bleeding diathesis and elevated PTT COPD: Disabling dyspnea at rest Oxygen dependent 02 saturation less than 88% Recurrent infections Poor response to bronchodilators Dementia or Alzheimer s Stage 7 or higher on FAST * Unable to ambulate alone * Unable to dress, bathe or feed self * Incontinent of bowel and bladder * Unable to speak or communicate meaningfully Presence of or history of at least 1 comorbid condition in the past year Ex: Weight loss, UTI, aspiration pneumonia, decubitus ulcers, etc. Neurological (CVA, Coma, Parkinson s, etc): State 7 or higher on FAST * Unable to ambulate alone * Unable to dress, bathe or feed self * Incontinent of bowel and bladder * Speech limited Karnofsky < 40% Poor nutritional status, dysphasia, and/or > 10% wt loss Renal Disease: Elevated BUN and Creatnine Urine output < 400 ml/24 hours Patient/Family choose to stop dialysis Hepatorenal syndrome Nightingale Hospice Improves the Quality of Life For Patients with: Cancer Cardiovascular Disease Congestive Heart Disease Chronic Obstructive Pulmonary Disease (COPD) Dementia or Alzheimer s Disease Neurological Disease (Parkinson s, ALS, etc.) Renal Disease Liver Disease Acquired Immune Deficiency Syndrome (AIDS)... 5

4 Neurological Diseases How Nightingale Helps Stroke (CVA) Physician diagnosis of CVA with confirmation of non-recovery is necessary. Must have ONE of the following (#1, #2, or #3) * Post Stroke Dementia with: * Stage 7 on FAST scale * Cannot dress, bathe or ambulate self * Incontinent of bowel and bladder, intermittent or constant * No meaningful verbal communication, stereotypical phrases only, or the ability to speak is limited to six or fewer intelligible words * Poor functional status with Karnofsky score of < 40% * Poor nutritional status with inability to maintain sufficient fluid * Calorie intake with > 10% weight loss during previous 6 months or serum albumin < 2.5 gm/dl Coma Physician diagnosis of Coma with confirmation of non-recovery is necessary. Comatose patients with any 3 of the following on day 3 of coma: * Abnormal brain stem response * Absent verbal response * Absent withdrawl response to pain * Serum creatinine > 1.5 mg/dl Management of Symptoms Personalized management of ADLs Individualized POC to meet patient s needs Speech therapy to assist in meeting communication needs Safety measures Occupational therapy to modify ADLs Support for patients and families Psychosocial support Spiritual support Community resource Help with end of life planning Prepare advance directives, funeral arrangements, obtain DNR order Provide medications, supplies and equipment related to terminal diagnosis Educate regarding nutrition and hydration issues Offer standardized wound protocol Reduce unnecessary ER visits and hospitalizations Attend and pronounce deaths Provide bereavement care Medical Complications for both CVA and Coma Must have had ONE of these in the past 12 months: * Aspiration pneumonia * Upper urinary tract infection (pyelonephritis) * Sepsis * Stage 3-4 decubitus ulcers * Fever recurrent after antibiotics... 7

5 Patients with Cancer How Nightingale Helps - Supportive Care Treatments not curing disease Failed multiple treatments Increasing pain and/or symptoms Multiple trips to hospital for symptom management Metastasis and/or Stage 3 or 4 Toxicity outweighs benefits Poor performance status * ECOG of 3-4 * Karnofsky < 50 Terminal prognosis with only a few treatments left Exhausted patient and family/caregivers Treatment is having negative impact on patient s quality of life Patient/family wants to stop curative treatment Consultations available 24 hours a day 7 days a week Expertise in pain and symptom management Pain evaluated on every visit and call Daily contact Psychosocial and spiritual counseling services End of life planning and life review 4 levels of care Radiation and/or chemotherapy treatments on an individualized basis Use of non-pharmacological therapy 24 hour availability of professional staff including RN, psychosocial, and physician Medications, equipment and supplies related to symptom management of the terminal diagnosis Communication and patient updates as determined by the referral source 13 months of bereavement services... 9

6 Debility Unspecified Case Study Multiple diagnosis without 1 being prevalent Functional decline with a change in condition over the past 3-6 months At least 1 co-morbidity in the past 12 months. Examples include: * Urinary tract infection * Upper respiratory infection * Decubitus ulcer * Sepsis * Recurrent fever, after antibiotics Weight loss Hospitalizations or emergency room trips Change in cognitive level in the past 3-6 months Desire for palliative care Mr. Smith is an 89 year old male who presents with dx of CAD, CHF, CVA, prostate cancer, diabetes, and anemia. He has SOB on extreme exertion, tachycardia and had a UTI 3 months ago. He has minimal conversation. He was able to ambulate with assistance until he experienced a fall and subsequent emergency room trip 6 months ago. Currently he is wheelchair bound. Mr. Smith has a DNR status and requests no further hospitalizations. During the past 6 months he has had a 7% weight loss. His current weight is 130 and height is 5 ft. 10 in. He used to consume 80% of meals. He used to eat with others but now chooses to stay in his room. He has a Stage 2 decubitus ulcer. This patient would be eligible for hospice services based on: Co-morbidities including recent UTI, decubitus ulcer, tachycardia Changes in ADLs and socialization Falls, emergency room visits Weight loss, decreased appetite, hand fed DNR status, desiring palliative care... 11

7 Renal Disease Case Study The patient is not seeking dialysis or renal transplant Creatinine clearance < 10 cc/min (< 15 for diabetes) Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetes) Supplemental: Presence of co-morbid conditions in acute renal failure is helpful * Examples may include advanced cardiac disease, chronic lung disease, cachexia, Albumin < 3.5 gm/dl, etc. Presence of signs and symptoms in chronic renal failure is helpful * Examples include uremia, oliguria (<400cc/day), hyperkalemia (> 7.0) not responsive to treatment, hepatorenal syndrome, etc. Mr. Hernandez, a 56 year old male, with a history of Type 2 diabetes, hypertension and peripheral vascular disease, has been having a hemodialysis 3 times a week for 4 years. He has been unable to work for the past 2 years. Prior to going on dialysis his creatinine was 6.5 and he had labile blood sugars. Lately he feels wiped out after the treatments and complains of pruritis, nausea and sleep disturbances. He has expressed to the dialysis nurse that he is considering stopping dialysis. He does not have a DNR order or an advance directive. He is married with 2 teenage children and his wife is disabled. The team members assist him by discussing treatment options and advance directives and provide both psychosocial support to both him and his family. His symptoms are controlled and his quality of life improved. He dies peacefully at home 2 weeks later

8 Continuous Care Benefits of Nightingale s Continuous Care Uncontrolled Symptoms: * Pain * Agitation * Delirium * Nausea/vomiting * Shortness of breath * Respiratory distress * Intractable diarrhea * Acute depression * Acute anxiety/terminal restlessness * Imminent death Conditions: * Fractures * Open lesions requiring frequent care * Complex wound care * Uncontrolled symptoms causing caregiver breakdown * Fear of dying requiring intensive interventions * Collapse of caregiver support requiring skilled care * Caregiver education for complex medications or treatment regimen *Other circumstances may arise where the interdisciplinary team determines the patient s condition requires a higher level of care Continuous Care is provided to patients where they reside in the comfort of their homes, long-term care settings and assisted living communities. This level of care helps patients and families during times of crisis. Patients who are receiving hospice care may be appropriate for short-term Continuous Care for symptom management and conditions requiring skilled intervention. Patients may also be discharged from the hospital to Continuous Care for intensive teaching, symptom management and/or frequent adjustment of medications. Features of Continuous Care One on one care provided until pain and/or symptoms are managed Emotional support provided to caregiver during crisis Daily RN assessment of symptom management and/or specific needs Caregiver education regarding treatment and medication regimens, safety and symptoms of dying Patient remains in his or her residence Continuous Care is short-term and used to maintain a patient in the patient s residence during periods of crisis

9 Failure to Thrive Case Study Unexplained weight loss Malnutrition or nutritional impairment * BMI < 22kg/m2 (BMI (kg/m2) = 703 x (wt in lbs)/ (ht in inches)2) * Below mid-arm circumference averages based on age and gender Disability * Karnofsky < or = 40% Possible Presenting Symptoms: Weight loss Anorexia Weakness Dizziness related to: * Hypotension (Systolic <90mm/Hg) * Electrolyte imbalance * Anemia Memory Loss Depression Change in ability to perform ADLs Mrs. Jones is an 86 year old female who has dx of anemia and weight loss. According to staff she is wasting away, withdrawn and has given up. She sleeps 15 hours a day. She has had weight loss of >13% in the past 6 months and currently weighs 91 lbs. She pushes food away and the time required to feed her has increased to 30 minutes per meal. She was able to feed herself 6 months ago. Mrs. Jones family requests neither feeding tube nor hospitalizations. She requires assistance with all ADLs. She is contracted and no one is certain of her height. Her mid-arm circumference is 23 cm. She was hospitalized with a URI 5 months ago. This patient would be eligible for hospice services based on: * >10% weight loss * Mid-arm circumference * Refusal of aggressive tx * Unable to feed herself * Pushing food away * Dependence in all ADLs * History of URI * Fat affect... 17

10 Cardio Pulmonary Disease Persistent symptoms of recurrent CHF at rest Optimally treated with diuretics and vasodilators (ACE inhibitors) New York Heart Class IV Ejection Fraction of 20% or less Increased Physician visits Multiple hospitalizations or ER visits Supraventricular arrhythmias that are resistant to arrhythmia therapy History of unexplained syncope History of Cardiac Arrest or MI Hypoxia at rest on room air po2 < or =to 55mm Hg Oxygen saturation < or = to 88% Severe, chronic lung disease as evidenced by: Disabling dyspnea at rest, poorly or unresponsive to bronchodilators Increasing visits to the ER or hospitalizations for respiratory infections and/ or respiratory failure Supplemental: Hypercapnia pco2 = to or > 50mmHG Unintentional progressive weight loss > 10% of body weight over the preceding 6 months Resting tachycardia > 100/minute Presence of cor pulmonale or right heart failure (RHF) Co-conditions: Pulmonary Disease Renal Disease Symptoms: Inability to carry on any physical activity without pain or SOB Pain and/or SOB increase with physical activity Increased fatigue Orthopnea Paraxysmal Nocturnal Dyspnea JVD Cachexia or Weigh Gain Case Study Mr. Taylor is a 68 year old male who has a history of CABG, MI, and co-morbidity of emphysema. He is non-compliant with multiple cardiac medications, is a full code and gets SOB while talking. He makes frequent calls to the physician, has acute respiratory exacerbations and recently was hospitalized for pneumonia. Physician referred patient to Nightingale and the follow occurs: * Medications related to symptom management of terminal illness paid for by Nightingale * Nurse assessment and education leading to increased compliance and increased patient comfort * Decreased SOB, pain and anxiety * Social Worker counsels patient/family regarding advance directive * Psychosocial and spiritual support for Mr. Taylor and family * Daily contact * Higher level of care provided during crisis * Decreased phone calls from patient/family to physician office * Nightingale staff present at death * 13 months of bereavement... 19

11 About Nightingale At Nightingale, we don t believe patients and family members should have to make multiple phone calls to find out what services are available. Nightingale offers a truly different healthcare experience, offering most all healthcare services a patient may need in one convenient location your home. Nightingale is rated among the top home healthcare providers in the nation. We stand firm behind our commitment that All Patients Come First. TM Nightingale Hospice Ph: Carmel, IN Fort Wayne, IN Fax: